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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 61
| Issue : 1 | Page : 76-77 |
Aortic dissection presenting as acute stroke: Careful selection of patients for intravenous thrombolysis
Swati Dayanand Chinchure1, Gaurav Goel1, Vipul Gupta1, Atma Ram Bansal2, Dilip Singh2, Arun Garg2, Ajaya Nand Jha3
1 Department of Neurointervention, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001, India
2 Department of Neurology, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001, India
3 Department of Neurosurgery, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001, India
| Date of Submission | 02-Nov-2012 |
| Date of Decision | 09-Dec-2012 |
| Date of Acceptance | 10-Dec-2012 |
| Date of Web Publication | 4-Mar-2013 |
Correspondence Address:
Gaurav Goel
Department of Neurointervention, Institute of Neurosciences, Medanta, The Medicity, Sector-38, Gurgaon, Haryana - 122 001
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.108017
How to cite this article:
Chinchure SD, Goel G, Gupta V, Bansal AR, Singh D, Garg A, Jha AN. Aortic dissection presenting as acute stroke: Careful selection of patients for intravenous thrombolysis. Neurol India 2013;61:76-7 |
How to cite this URL:
Chinchure SD, Goel G, Gupta V, Bansal AR, Singh D, Garg A, Jha AN. Aortic dissection presenting as acute stroke: Careful selection of patients for intravenous thrombolysis. Neurol India [serial online] 2013 [cited 2023 Feb 6];61:76-7. Available from: https://www.neurologyindia.com/text.asp?2013/61/1/76/108017 |
Sir,
A 38-year-old male presented with acute onset left hemiparesis and slurring of speech of 3 hours duration. On Admission, National Institute of Health Stroke Scale score was 13 and blood pressure was 100/60 mmHg. Computed tomography (CT) scan brain plain showed no hemorrhage [Figure 1]a. Bolus of intravenous recombinant tissue plasminogen activator (rtPA) was given on CT table awaiting CT perfusion (CTP) and CT angiogram (CTA) of neck and brain. CTP graph showed extreme delay in contrast arrival with no reasonable maps [Figure 1]b. CTA reconstruction images showed normal intracranial vasculature [Figure 1]c and dissection flap extending from the aortic root to innominate artery [Figure 1]d with a clot in right innominate and right common carotid artery [Figure 1]e. Intravenous thrombolysis was stopped immediately. Repeat examination showed near total recovery of the neurological deficit. Patient made good clinical recovery and was taken for aortic surgery after 24 hours. | Figure 1: (a) Noncontrast enhanced CT shows no e/o acute cerebral infarct/intracerebral bleed. (b) CT perfusion graph Shows extreme delay in contrast arrival. This type of graph is usually seen in older patients with severely reduced ejection fraction. (c) CT angiography reconstruction images show normal intracranial vasculature. (d) Dissection flap extending from the aortic root to innominate artery and (e) filling defect-clot in proximal innominate artery
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Aortic artery dissection (AAD) may present as an acute ischemic stroke in 5-10% patients. [1] Extension of the dissection flap to the supra-aortic area with obstruction of the common carotid arteries is implicated as the most common mechanism. [2] Preferential flow changes in right sided vessels in Stanford type A dissection is responsible for predominant left hemiparesis in these patients with aortic dissection. [3],[4] According to Iguchi et al., [3] warning signs for acute stroke with AAD are asymmetrical pulses, hypotension and/or left hemiparesis. Hypotension was the only warning sign in our patient. Patients with AAD mimicking acute myocardial infarction who have been inadvertently treated with IV rtPA have suffered dire complications, including extension of dissection into the pericardium, leading to cardiac tamponade and death. [5] Thrombolysis is contraindicated in acute ischemic stroke caused by AAD because of the risk of fatal intracerebral hemorrhage, aortic rupture, and cardiac tamponade [6] although there are few reports of favorable outcome after IV thrombolysis in AAD. [7] IV Thrombolysis can also delay surgery. To conclude, because of narrow time window for effective IV thrombolysis, underlying etiology causing stroke may not be investigated properly. IV thrombolysis needs careful selection of patient to prevent life threatening complications. Particular attention should be paid to 'red flags' like hypotension and 'left sided' hemiparesis. Ideally CTA may be needed in acute stroke presenting within window period to evaluate for possibility of further intraarterial interventions. We recommend including aortic arch and origins of major neck vessels in CTA in acute stroke protocol as a routine to avoid missing out AAD, which can present as acute stroke.
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